Patient Education and Counseling 50 (2003) 2732
Communication in context: new directions in communication researchJozien Bensing, Sandra van Dulmen, Kiek Tates
NIVEL, P.O. Box 1568, 3500 BN Utrecht, The Netherlands
By focusing attention almost exclusively on a single encounter, researchers have adopted a rather restricted view on studying communi-cation in health care. After all, communication does not take place in a vacuum but is influenced by the context in which it takes place. Wewould therefore strongly recommend to broaden the perspective of communication research. In this respect, four lines of investigation areproposed, each guided by different theories. In the first, context is determined by the goals or targets aimed at by both parties in the medicalencounter. The second concerns the context of time, referring to the influence of previous and future medical encounters. The third is setup around the organizational context in which an interaction takes place and the last defines context by looking at a medical encounteras a meeting between two multifaceted parties. Studying a medical encounter in its broader context is expected to provide answers tointriguing questions such as why health care professionals do not always act in conformity with the general approved standards of highquality communication and how the factor time span can be used more effectively in the medical encounter. Eventually, a broader contextview will bridge the existing gap between theory and practice. 2003 Elsevier Science Ireland Ltd. All rights reserved.
Keywords: Medical communication; Context; Goals; Time; Organization; Multi-party
Research into medical communication is sometimes de-scribed as analyzing the black box of the doctors healingpower [1,2]. However, every now and then a picture emergesof communication researchers analyzing this black box as ifit was found in the bush after a plane crash: as an object initself, completely devoid of the wider context of the medi-cal dialogue. Most communication research has been exclu-sively focused on the dialogue between patient and doctor ornurse in itself, without taking account of its broader context.But no dialogue takes place in a vacuum; there is a wholeworld surrounding it. We strongly believe that this narrowfocus blinds communication researchers to many relevantissues, and hampers the progress of knowledge as well asits implementation in clinical practice.
Our central statement in this position paper is: We haveacquired enough knowledge in general of the value of com-munication skills. Now, it is time to focus our attention tothe study of specific contextual conditions that may broadenour knowledge and may help, hinder or complicate the ap-plication of this knowledge in everyday practice. The com-munity of researchers should feel challenged to look for new
Corresponding author. Tel.: +31-30-27-29-700;fax: +31-30-27-29-729.E-mail address: email@example.com (J. Bensing).
roads in order to substantiate the so often claimed centralposition of communication in clinical practice, medical ed-ucation, and in research programs.
2. Future challenges
A running thread in our position paper is the call for at-tention to the context of medical communication. In gen-eral, there is much agreementamong teachers as well asresearcherson the basics of good communication in healthcare. There is ample evidence that communication shouldbe considered as a powerful tool in medicine, not only inestablishing a workable relationship with the patient, butalso in both the diagnostic and therapeutic process . Ithas also been shown to work the other way around: Goodtechnical quality care, provided in an unsatisfactory envi-ronment and with unsatisfactory interactions will not pro-duce healthier patients , and negative expectancies in-crease the frequency with which patients report all kind ofsymptoms . Consciously or unconsciously, communica-tion plays a crucial role in medical practice. However, inorder to understand the real contribution of communicationto distinctive outcomes of health care, we are convinced thatcommunication has to be studied in its broader context, thecontext of aims and targets, the context of persons and or-ganizations, the context of place and time. By doing so, we
0738-3991/03/$ see front matter 2003 Elsevier Science Ireland Ltd. All rights reserved.doi:10.1016/S0738-3991(03)00076-4
28 J. Bensing et al. / Patient Education and Counseling 50 (2003) 2732
hope to bridge the gap between evidence-based medicineand patient-centered medicine  and to find empirical ev-idence for the mechanisms which foster or hinder patientswell-being, apart from the direct effects of the medical in-tervention itself: those mechanisms that are known to bepart of the much-discussed, but little-researched placebo-and nocebo-effects in health care .
There is, however, yet another challenge to meet: thechallenge of theory-driven research. Much communicationresearch is still descriptive in nature, more dictated by avail-able methodology than by rigorous application of dedicatedtheories. Descriptive research is useful in the earlier stagesof knowledge-production, when the domain-under-studystill has to be charted. Real breakthroughs in knowl-edge are, however, only possible by systematically testingtheory-guided hypotheses on presumed mechanisms behindthe (positive and negative) effects of communication. Webelieve that in health care the phase of exploratory anddescriptive research should and could be over.
3. Towards a new research agenda
Taken together, these two challenges can help us to definea research agenda for the next decade. Within the field ofcommunication in context, four lines of investigation shouldbe distinguished:
1. The context of goals or targets of both parties in the med-ical encounter (patient and physician or nurse), referringto the use of communication as a tool.
2. The context of time in relation to continuity of care whichnecessitates to investigate not only one single visit butto consider the role and influence of previous and futureconsultations and patients medical history as well.
3. The broader organizational context in which the dialoguetakes place, colored by policies regarding teamwork, timeconstraints and implicit and explicit priorities within themedical staff.
4. The context determined by what both multifacetedpartieson the one hand the patient and accompanyingwife, husband or child, on the other the physician, nurse,and/or other care providersbring to the health carevisit: needs, expectations and knowledge and attitudes,experience and skills, respectively.
In presenting these four lines of investigation, we do notclaim to provide an exhaustive overview of potential studiesin the area of context in health care. Our purpose is merely totouch on the, until now, underexposed fields of study. Eachof the lines of investigation will be elaborated and put in theproper theoretical perspective.
3.1. From general to specific
In line with the tradition in communication research, westarted by emphasizing the central role of communication
in health care. Sometimes this role is positive and leads tobetter understanding and coping, to better therapeutic deci-sions and more compliance; sometimes, however, the role ofcommunication is negative and leads to misunderstanding,dissatisfaction, wrong decisions and sometimes even mal-practice suits [3,9]. The success or lack of success can of-ten be ascribed to communication processes. It is importantthat doctors, nurses and other health care professionals areaware of the effects of their communication behavior andlearn to use it as the powerful tool it can be. It is similarlyimportant that communication researchers explore, unraveland test specific communication behaviors in relation to setmedical and nursing goals in order to provide health careprofessionals with empirical evidence for the singular itemsof their tool-box in relation to the problems at hand. Com-munication is a powerful tool, but only when it is used asa tool, or rather a set of tools, as consciously planned andtargeted interventions.
Aside from its well-known and widely trained genericcharacteristics (creating a good interpersonal relationship,exchange of information), concrete communication strate-gies and behaviors can be used to reach specified goalswithin medical and nursing care. As was shown by manyauthors, there is a multitude of different specific goals andsub-goals within health care [3,5,10,11]. Dependent on thephase of treatment and/or patient needs, medical encoun-ters may vary in what both participants aim at: getting orgiving reassurance, finding and telling the right diagnosticlabel, establishing a common agenda, weighing diagnosticand/or risk information, valuing preferred therapeutic op-tions and alternative solutions, making patient preferencesmore explicit, reaching a medical decision (shared or not),strengthening self-efficacy in maintaining difficult therapeu-tic regimens, acknowledging, fighting or relieving anxietyand depression, moral support in accepting the unaccept-able, comfort and strength. Even within one medical visitdifferent targets can be distinguished. It is essential that re-searchers should be aware of these multiple goals in healthcare encounters and realize that different goals ask for var-ied communication strategies that are based on a variety oftheoretical frameworks.
Let us give one example: How to create a good in-terpersonal relationship can best be predicted from psy-chotherapeutic theories with their heavy accent on affectivecommunication behaviors: friendliness, social courtesies,empathy, showing respect and understanding, uncondi-tional positive regard . However, these theories mightbe worthless and its accompanying behaviors sometimeseven contra-productive when trying to tackle the best hid-den taboo in medical encounters: non-compliance. Basedon self-regulatory theories , it can be predicted thatenhancing compliance asks for active problem-solving be-haviors, combined with active stress-reduction: motivatingpatients for taking responsibility, helping in setting realisticand tailor-made personal goals, helping in listing possi-ble barriers, showing understanding for incidental events
J. Bensing et al. / Patient Education and Counseling 50 (2003) 2732 29
of non-compliance and showing partnership in creativeproblem-solving. A nice example of what this might meanfor communication research is shown by Roter and Hall.
Different problems ask for specific tools, andthusfor specific communication strategies and behaviors. Thisposes communication researchers for methodological aswell as theoretical challenges. Methodological challengesare to be found in subdividing medical encounters in tomeaningful elements, and in innovative ways of analyzingcommunication data (sequential analysis, pattern analysis,critical incident analysis, cue responding, etc.). Theoreticalchallenges are to be found in applying theories that havebeen developed in clinical psychology, social psychologyand health psychology to the field of communication re-search and vice versa. As an additional advantage, this couldhelp to explain under which conditions theoretically basedbehavioral intervention programs are more or less success-ful when implemented in everyday practice. For, as statedabove: Good technical quality care, provided in an unsat-isfactory environment and with unsatisfactory interactionswill not produce healthier patients.
The issue is further complicated by the fact that thereare often individual differences in the targets patients mayhave. Again an example might be illustrative. This time itis about the recent paradigm on shared decision making.There is ample evidence that patients diagnosed with can-cer want to be adequately informed of their diagnosis andprognosis, but that many (but not all!) relinquish decisionalcontrol . Patients may feel burdened by the signifi-cance and consequences of making treatment decisions andmay prefer the physician to be accountable for the choicesmade. Therefore, advocating increased patient involvementfor every patient in every situation may well endanger ratherthan safeguard patient autonomy .
3.2. Towards a time perspective
In most communication research literature, there is hardlyany recognition of past or future. Continuity of care (withthe same or other health care providers) is a central issuein health care, but it is hardly an issue in communicationresearch . Most dialogues are studied as if previousconsultations did not leave the patient with specific uncer-tainties, hopes and expectancies, and as if everything hasto take place during the consultation under study. From thepatients perspective, receiving bad news may reflect theprocess of being diseased (e.g. by cancer), whereas researchon breaking bad news primarily focuses on how to provideinformation in the course of a single diagnostic consul-tation . In addition, previous contacts set the agendafor the future contacts and should be taken into consider-ation when examining the content, process and effects of asingle encounter.
Theories from research into the placebo-effect of theproviderpatient encounter [4,21,22] could well complement
the theoretical and methodological insights gathered sofar in studies into communication. Investigating the roleof conditioning and expectancies in ongoing encounterscould bring forward a new field of study not yet exploredwithin the field of medical communication. The theory ofclassical conditioning can, for instance, be used to explainwhy one patient suffers from serious side-effects (e.g. fromchemotherapy) and another one does not or why patientswith serious complaints respond positively to a treatmentand others with the same complaints do not. Apparently,previous experiences with certain treatments, hospitals ordoctors influence the way patients respond to future ones. Inview of the conditioning theory: a current treatment may beassociated with an earlier experience which has resulted ina reduction in negative symptoms, this earlier experience issaid to be positively conditioned as far as recovery and anx-iety reduction is concerned . This makes it extremelyimportant to look at patients medical history but also tolook at what actually happened in former visits and at theway physicians attend to patients experiences with healthcare so far. Eliciting patients past experiences with thehealth care system, including these subjective experiencescan help the clinician to understand patients reactions totreatment proposals, personal preferences and unspokenresistances.
The role of expectancies, the other central placebo theory, has more to do with explaining why experiences in thepresent influence future treatment outcome . Responseexpectations appear to be triggered by the information a per-son receives . Research shows that physiciansby theircommunication behaviorare able to influence patients ex-pectations in a positive as well as a negative direction.
From the neuro-cognitive sciences, it is known that thebrain can be blocked from acquiring new information whenpersons are under stress [25,26]. This means that in stressfulsituations information giving must be carefully dosed, re-peated and spread over more visits. It can be experimentallytested what delay is necessary to allow for new informationto be given to the patient. The role of stress-reducing com-munication techniques in this process is another topic of re-search. It is worthwhile to look for opportunities to combinethis line of research with neuro-imaging techniques, such asPET or MRI-scans.
3.3. Between knowing and doing
Chronic and life-threatening diseases go hand in hand withstrong emotions and much uncertainty. Doctors and nursesmay feel barriers in emotion-laden communication becauseit produces stress. From stress-coping theories, it can behypothesized that experienced stress in doctors and nurseswill lead to blocking behaviors as a coping strategy whilefacilitating communicative behaviors are needed from thepatients point of view [27,28]. This could explain the dis-crepancy between doctors attitudes, which tend to be ratherpatient-centered in general, and patients assessments of the
30 J. Bensing et al. / Patient Education and Counseling 50 (2003) 2732
quality of care, which focus on problems in information giv-ing and personal care .
Doctors and nurses may not only feel stressed as a resultof not being able to relieve the burden of the disease fromtheir patients shoulders, but also as a result of organiza-tional demands. Time constraints and schedules, treatmentprotocols and institutional norms and values may all dis-tract attention from patients needs for individualized care.Time constraints, for instance, force many physicians to in-terrupt their patients flow of speech at the beginning ofthe consultations . Providers, convinced that they knowpatients reason for encounter, may incorrectly focus on anissue which is not the patients main concern. This may en-gender the risk of making incorrect diagnoses and of givinginappropriate advices on the part of the physician and dis-satisfaction, non-compliance and second opinion-seeking onthe part of the patient. A recent study shows that cancer pa-tients indeed often seek a second opinion because they aredissatisfied with the way they have been treated by the firstphysician . Although the issue of time has frequentlybeen attended to in communication research, it has, so far,mostly been examined in a retrospective way, i.e. by exam-ining the communication process in relation to consultationlength . Less attention has been given to the influenceof the time pressure experienced by a health care providerat the beginning of the visit on the actual communicationprocess.
In addition, treatment protocols and guidelines devel-oped to improve and standardize the information exchangemay also hinder a patient-centered process. Institutionalizednorms and values, reflected in a supervisors attitude towardsgood health care, are also likely to color the actual commu-nication process. A supervisor may play a fairly prominentrole in explaining why communication skills thoroughlyacquired in training are not observed in real-life nursingcare . The extent in which a supervisor supports thenurses communication style appears to have a large impacton the actual communication process. Especially affectivecommunication suffers from such contextual constraints.
From the theory of cognitive dissonance it can be hypoth-esized that doctors and nurses who are highly dependent onorganizational norms and values will tend to conform to thisat the cost of care tailored to the patient, while doctors (andto a lesser degree nurses) who prioritize patient care aboveinstitutional demands probably show more patient-centeredcommunication behavior.
3.4. Beyond the dialogue
Traditionally, research on providerpatient communi-cation has focused on the doctorpatient dyad. Yet, indaily medical practice, physicians often find themselvesfaced to communicate with an elaborate and complicatedpatient-system. Many health care visits, especially thosewith a strong emotional component in case of patients with alife-threatening disease, involve more than two participants:
an elderly patient accompanied by a spouse or adult child,couples visiting a doctor, parents consulting a doctor fortheir child or, in case of non-native speakers, interpreterssupporting a patient.
Due to the myopic dyadic perspective there has beenlittle empirical exploration on the role and influence of athird (or fourth) persons presence on the process, contentand outcome of the medical visit. The scarce research onmulti-party medical interactions within the setting of pedi-atrics , geriatrics , dietary counseling  andthe general practitioners surgery [39,40] showed that themere presence of a third person changes the dynamics of themedical interaction, no matter how small the third personsconversational contribution to the actual visit. After all, inattending a health care provider, patients have their agenda(needs and expectations) but so have the persons accompa-nying the patient. In order to communicate effectively, thehealth care provider should not only consider the patientsviewpoints but those of their relatives as well.
In emotionally laden consultations, caregivers or relativesare likely to make themselves especially felt. Therefore,an appropriate avenue for future communication researchwould be to explore the implications regarding participantroles and responsibilities beyond the scope of the medicaldialogue. In view of the social support theory, the relativespresence should not be ignored but rather be encouraged forits positive impact on the patients quality of life . Fruit-ful theoretical frameworks may be derived from social psy-chology, in particular from social support theories  andtheories on family coping . Many of these theories leadto explicit assumptions about communication behaviors thatare beneficial or detrimental for the patients well-being.
Not only patients are part of a larger system, even withinthe consultation room. Future research should also pay at-tention to the multifaceted character of the health care sys-tem itself. Patients are often confronted with a broad rangeof health care providers, such as specialists, nurses, and ra-diologists. These providers are likely to differ in attitudes,experience and skills. Inadequate communication, due todiscordance in information or insufficient fine-tuning of in-formation conveyed by the various providers, can lead toconfusion for patients about the diagnosis, the prognosis andthe future management plans. Studies indeed showed thatpatients often feel overwhelmed by contradictory advice oran overloaded information supply emanating from multidis-ciplinary sources . Not only may this cause unnecessarystress for patients, but also for health care providers them-selves. After all, effective communication has shown to beimportant for the efficiency, morale and work satisfaction ofthe individual providers . So far, however, little data areavailable on how the process of information exchange be-tween provider and patient is influenced by factors such astask-distribution and delegation and fine-tuning and check-ing of the information conveyed. Research into the expecta-tions of breast cancer team members of their own and eachothers roles in providing information to women with breast
J. Bensing et al. / Patient Education and Counseling 50 (2003) 2732 31
cancer showed that even the members of these multidisci-plinary teams are not completely acquainted with the infor-mational roles and responsibilities of their colleagues .These findings may cause concern, as one of the tenets ofthis type of multidisciplinary care is the provision of com-prehensive and consistent information. Further research isrequired to capture health care providers views on what theyconsider as their individual task and responsibility in theprocess of exchanging and tailoring the information supply.
Decontextualized dyadic analyses are bound to fail in fullyexposing the dynamics of multi-party medical communica-tion. By acknowledging the multi-party character of med-ical communication, future research will have to take intoaccount the context of the medical communication both onthe patients and on the providers side. Fruitful areas of re-search might also be communication studies on small groupinteractions and organizational theory on interdisciplinarycollaboration. New advances are to be made in order to cap-ture the impact of these contextual factors on the course andoutcome of the medical dialogue.
In this paper, we proposed to expand the focus of commu-nication research and to incorporate the context in which asingle health care visit takes place. This broader context wasdefined in four different ways, i.e. by referring to the multi-ple goals of and within a medical encounter, by incorporat-ing the concept of time which necessitates to look beyond asingle encounter, by considering the organizational contextof treatment policy and constraints, and by acknowledgingthe fact that a large number of encounters include more thantwo parties. In proposing these lines of research our pointof departure was the actual communication process withinhealth care, not the context itself, which could of course, bedefined in a number of alternative ways.
In the way defined in the present paper, the broader contextperspective is considered to be necessary to find out, forinstance, why health care professionals do not always actin conformity with the general approved standards of highquality communicationalthough they are known to havemastered the skills in training, how the factor time spancan be used more effectively in the medical encounter andwhat the reasons are why patients not always disclose theirconcerns assessed prior to the health care visit. Eventually,a broader context view will bridge the existing gap betweentheory and practice.
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Communication in context: new directions in communication researchIntroductionFuture challengesTowards a new research agendaFrom general to specificTowards a time perspectiveBetween knowing and doingBeyond the dialogue